Catching Up With the 2017 North American Pain School Visiting Faculty: A Conversation With Daniel Clauw

Editor’s Note: The second North American Pain School (NAPS) took place June 25-29, 2017, in Montebello, Quebec, Canada. An educational initiative of the International Association for the Study of Pain (IASP) and Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), and presented by the Quebec Pain Research Network (QPRN), NAPS brings together leading experts in pain research and management to provide 30 trainees with scientific education, professional development, and networking experiences. This year’s theme was “Where Does it Hurt and Why: Peripheral and Central Contributions to Pain Throughout the Body.” Six of the trainees were also selected to serve as PRF-NAPS Correspondents, who provided first-hand reporting from the event, including interviews with NAPS’ six visiting faculty members and summaries of scientific sessions, along with coverage on social media. This is the first installment of interviews from the Correspondents, whose work is featured on PRF and RELIEF, PRF’s sister site for the general public.

Daniel Clauw, MD, is Professor of Anesthesiology, Medicine (Rheumatology) and Psychiatry at the University of Michigan, Ann Arbor, US. He also serves as Director of the Chronic Pain and Fatigue Research Center there. He is a rheumatologist and clinical investigator and fibromyalgia is one of his major focuses. Clauw sat down with PRF-NAPS Correspondent Shana Burrowes, a graduate student and epidemiologist at the University of Maryland, Baltimore, US, to discuss his background as a doctor and researcher, the current state of healthcare for pain, and some of his latest thinking about fibromyalgia. Below is an edited transcript of their conversation.

You are both a doctor and a clinical investigator. Why did you go into patient research?
I was trained as a rheumatologist, but early in my career I was fortunate enough to stumble upon research opportunities. In particular, before I had completed my fellowship training I had become the world’s expert on a very rare condition called eosinophilia myalgia syndrome (EMS). What lit a fire underneath me was that I became a first author on a JAMA article that described seven people with EMS, which was later traced back to people who were taking tryptophan. At the time in the US, tryptophan was available as a nutritional supplement over the counter, and it turned out that one of the manufacturers of it somehow introduced a contaminant that caused EMS. I became so excited by writing that article and then becoming a researcher by, if you will, learning on the job.

One of the things I did early on that turned out to be extremely helpful—and, to this day, I think it’s what has made me successful as a scientist—was to embrace team science. Because I wasn’t formally trained in research I identified a number of different people with PhDs in psychology, brain imaging and quantitative sensory testing (QST). I figured out a way to bring them into a research team and create win-win relationships where they got something out of being on the team and the team got something out of having them be there.

Has team science affected the way you think about chronic pain—do you see it in a more holistic way, for example?
Yes, I have developed a more holistic view. When you do team science and you do it well—when the different people on the team really appreciate the contributions of other members of the team—all of a sudden you do look at things much more broadly. And the more you do that, the more you see commonalities across chronic pain conditions.

There is research supporting nonpharmacological interventions for chronic pain, yet these treatments aren’t being promoted at the bedside. Why?
There’s a lot of blame to go around, but the only thing that’s going to solve this problem is when we move from a fee-for-service system to a pay-for-performance system. We need to reach a point in this country where hospitals or big clinics that manage pain patients will be paid based on how well they do that, not on how many procedures, injections, surgeries or MRIs they perform. If and when that happens, the pendulum will dramatically shift.

Right now, if a low back pain patient comes into the office, a doctor can make a fair amount of money injecting a drug into that person, and the reality is that patients want a quick fix; they don’t want to be told that they need to look at a website that provides cognitive behavioral therapy and says they should play a more active role in managing their own pain. They want the powerful procedure or drug so that they don’t have to do anything.

These patient expectations are similar in other settings, such as when parents take their children who have colds into the doctor but want an antibiotic for their kids. In that case, the quality improvement measure is a report card that tracks how often a pediatrician prescribes an antibiotic when someone comes in; all of a sudden prescribing will go way down. But this hasn’t happened in the pain field. No one is being penalized and physicians are making a huge amount of money.

Is it difficult to implement such quality improvement measures?
Some of these problems are more amenable to these simple solutions than others. Say, for example, that you identify surgeons who do a procedure, and then after that procedure, you can show they are prescribing 90 days’ worth of hydrocodone, but on average people only need two days’ worth. If you put this in a report card and show what surgeons are prescribing versus what patients actually need, you can immediately get those surgeons to change their behavior because they don’t want to be the ones causing the opioid problem.

The problem with the pain field is that you’re not going to get the orthopedic surgeons, neurosurgeons or the proceduralists at an institution to agree that the procedure they do doesn’t help people and shouldn’t be done. This is because the patients want it and the physicians make a lot of money doing it.

Some third-party payers have become smart about this and have tried, for example, to cut down on unnecessary surgery or injections for low back pain. Do you know who will be the first ones to show up at the payers’ doors and tell them they can’t do this? You would think it would be the surgeons or the anesthesiologists, but it’s the patients; a patient says, “I want the procedure and the payers can’t tell my doctor not to do it because I know it’s going to help me and my doctor says it’s going to cure my pain.” And so the third-party payers keep reimbursing the procedure.

Earlier you talked about the importance of teamwork in research. Do you think chronic pain patients should be seen by a team of doctors in the clinic?
Absolutely, and this has to conform with a patient-centric self-management approach. A big part of what the team has to do is say to patients that they have a personal responsibility to work on getting better. We do that for chronic obstructive pulmonary disease (COPD) and congestive heart failure, for example, but chronic pain is one of the few medical illnesses where that patient-centric approach hasn’t gained a foothold.

One of the biggest problems is that the impetus for these programs and for a hospital or a third-party payer to put them into place is that if you don’t, people end up being admitted to the hospital, and you can show that you can save costs. But that doesn’t happen to chronic pain patients—we don’t admit people for pain. So, in that sense, if you don’t adequately take care of a chronic pain patient, there isn’t a higher cost to the system.

Once someone has had chronic pain for 20 years, it’s almost impossible to get them to start an exercise program. But if they’re 6 to 12 months into their chronic pain and you start the program then, they can do it. But we don’t do that. We should be putting the money towards the primary care physicians and interdisciplinary teams that could manage these people better, at an earlier stage.

Let’s switch gears to talk about fibromyalgia, which is one of your major areas of research. At NAPS you discussed the “FMness” self-report measure that you developed for clinical use, which considers fibromyalgia symptoms as being on a continuum. How is that measure applied now in clinical practice?
We use it at the University of Michigan in a lot of our clinics. After we do grand rounds somewhere, either the surgeons or the anesthesiologists at the institution will say they want to measure FMness. Even if they just narrowly use the fibromyalgia measure to predict the people who will need more opioids to control their pain after surgery, they can then better manage these patients.

What we’re really trying to do is show people that if they use a couple of these validated self-report measures prior to surgery, they could identify some patients who are probably not going to do well with surgery, and so they may or may not decide to do the surgery on them. But at least they should counsel patients that they’re not going to do as well if, for instance, they have knee pain plus additional risk factors, compared to someone who just has knee pain. Then the patient makes a very reasoned choice.

Is FMness independent of psychosocial comorbidities like stress, depression and catastrophizing?
It’s not totally independent, but it only has about 20-25% shared variance. If people are more stressed they’ll have higher FMness, if they have lower socioeconomic status (SES) they will, on average, have higher FMness, but it is largely independent of classic psychological factors.

What we’re saying is that fibromyalgia is not the same as those factors and that if you deal with them you’re not dealing with fibromyalgia; many people who are not anxious, depressed, or catastrophizing have a higher fibromyalgia score. What is probably more important in terms of pain is how their central nervous system is wired.

How important are genetic factors in fibromyalgia?
The studies of fibromyalgia per se, as a standalone diagnosis, have suggested about half is due to familial predisposition, and half to environmental factors. Having said that, we haven’t identified any genes with powerful effects, so it’s probably a polygenic condition. But the phenotype is so clear—once you get used to identifying it, you can walk into an exam room and within a minute or two really pick up on where the patient is along this continuum.

When someone’s chief complaint is chronic pain, the first thing a physician or any other healthcare provider should do is seek a more nuanced view and ask the patient to talk about his or her pain. The more random the pain is, the more that it moves from one location to another, the more that it can’t be localized, then the more likely it is that it’s coming from the brain. This doesn’t require a self-report measure; you just have to re-teach clinicians that doing a really nuanced history, and then asking about pain elsewhere in the body, will allow them to see quite quickly how patients are doing.

Are subclinical patients harder to pick up by interview?
Yes; the lower the score, the harder it is, but you still become pretty good at doing it.
It’s not just the number of pain sites. We started to look at this because we have fibromyalgia scores on 35,000 people who have undergone surgical procedures. If you just look at the location of pain, there are certain locations, such as the bilateral thighs or bilateral upper arms, where pain only occurs if there’s a problem in the central nervous system. There are no joints in those locations; autoimmune diseases don’t cause pain there.

“Central” might not be the exact correct term, I’m evolving over time to say that maybe the better term would be “systemic.” Someone starts out with a peripheral pain condition, and then for long periods of time they’re just not sleeping as well as they used to because they hurt, or they become less active. Some of those effects of inactivity or poor sleep are almost certainly mediated by the central nervous system, yet some of them could be peripheral as well, but they’re more widespread—they’re systemic effects. When I talk to clinicians, I’m just trying to get them to see that fibromyalgia is not just a problem in the joint.

Additional Reading

Challenges of implementing fibromyalgia treatment guidelines in current clinical practice.
Arnold LM, Clauw DJ
Postgrad Med. 2017 Jun 19:1-6.

Neurobiology of fibromyalgia and chronic widespread pain.
Sluka KA, Clauw DJ
Neuroscience. 2016 Dec 3; 338:114-129.

Preliminary Validation of the Michigan Body Map (MBM).
Brummett CM, Bakshi RR, Goesling J, Leung D, Moser SE, Zollars JW, Williams DA, Clauw DJ, Hassett AL
Pain. 2016 Jun; 157(6):1205-12.

Fibromyalgia: a clinical review.
Clauw DJ
JAMA. 2014 Apr 16; 311(15):1547-55.

Fibromyalgia: from pathophysiology to therapy.
Schmidt-Wilcke T, Clauw DJ
Nat Rev Rheumatol. 2011 Sep; 7(9):518-27.

Clauw et al., 1990 PMID: 2308182